1
|
Hügel M, Stöhr J, Kuhnt T, Nägler F, Papsdorf K, Klagges S, Hambsch P, Güresir E, Nicolay NH, Seidel C. Long-term survival in patients with brain metastases-clinical characterization of a rare scenario. Strahlenther Onkol 2024; 200:335-345. [PMID: 37646818 DOI: 10.1007/s00066-023-02123-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 07/10/2023] [Indexed: 09/01/2023]
Abstract
PURPOSE This study aimed to assess clinical, treatment, and prognostic features in patients with brain metastases (BM) from solid tumors achieving long-term survival (LTS). Further, the accuracy of diagnosis-specific Graded Prognostic Assessment scores (ds-GPA) to predict LTS was evaluated. METHODS Patients admitted for radiotherapy of BM between 2010 and 2020 at a large tertiary cancer center with survival of at least 3 years from diagnosis of BM were included. Patient, tumor, treatment characteristics and ds-GPA were compiled retrospectively. RESULTS From a total of 1248 patients with BM, 61 (4.9%) survived ≥ 3 years. In 40 patients, detailed patient charts were available. Among LTS patients, median survival time from diagnosis of BM was 51.5 months. Most frequent primary tumors were lung cancer (45%), melanoma (20%), and breast cancer (17.5%). At the time of diagnosis of BM, 11/40 patients (27.5%) had oligometastatic disease. Estimated mean survival time based on ds-GPA was 19.7 months (in 8 cases estimated survival < 12 months). Resection followed by focal or whole-brain radiotherapy (WBRT) was often applied (60%), followed by primary stereotactic radiotherapy (SRT) (20%) or WBRT (20%). 80% of patients received systemic treatment, appearing particularly active in specifically altered non-small lung cancer (NSCLC), melanoma, and HER2-positive breast cancer. Karnofsky performance score (KPS) and the presence of oligometastatic disease at BM diagnosis were persisting prognostic factors in LTS patients. CONCLUSION In this monocentric setting reflecting daily pattern of care, LTS with BM is heterogeneous and difficult to predict. Effective local treatment and modern systemic therapies often appear crucial for LTS. The impact of concomitant diseases and frailty is not clear.
Collapse
Affiliation(s)
- M Hügel
- Department of Radiation Oncology, University of Leipzig Medical Center, Leipzig, Germany
| | - J Stöhr
- Department of Radiation Oncology, University of Leipzig Medical Center, Leipzig, Germany
| | - T Kuhnt
- Department of Radiation Oncology, University of Leipzig Medical Center, Leipzig, Germany
| | - F Nägler
- Department of Radiation Oncology, University of Leipzig Medical Center, Leipzig, Germany
| | - K Papsdorf
- Department of Radiation Oncology, University of Leipzig Medical Center, Leipzig, Germany
| | - S Klagges
- Clinical Cancer Registry, Leipzig, Germany
| | - P Hambsch
- Department of Radiation Oncology, University of Leipzig Medical Center, Leipzig, Germany
| | - E Güresir
- Department of Neurosurgery, University of Leipzig Medical Center, Leipzig, Germany
| | - N H Nicolay
- Department of Radiation Oncology, University of Leipzig Medical Center, Leipzig, Germany
| | - C Seidel
- Department of Radiation Oncology, University of Leipzig Medical Center, Leipzig, Germany.
| |
Collapse
|
2
|
Mashiach E, Alzate JD, De Nigris Vasconcellos F, Bernstein K, Donahue BR, Schnurman Z, Gurewitz J, Rotman LE, Adams S, Meyers M, Oratz R, Novik Y, Kwa MJ, Silverman JS, Sulman EP, Golfinos JG, Kondziolka D. Long-term Survival From Breast Cancer Brain Metastases in the Era of Modern Systemic Therapies. Neurosurgery 2024; 94:154-164. [PMID: 37581437 DOI: 10.1227/neu.0000000000002640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 06/14/2023] [Indexed: 08/16/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Median survival for all patients with breast cancer with brain metastases (BCBMs) has increased in the era of targeted therapy (TT) and with improved local control of intracranial tumors using stereotactic radiosurgery (SRS) and surgical resection. However, detailed characterization of the patients with long-term survival in the past 5 years remains sparse. The aim of this article is to characterize patients with BCBM who achieved long-term survival and identify factors associated with the uniquely better outcomes and to find predictors of mortality for patients with BCBM. METHODS We reviewed 190 patients with breast cancer with 931 brain tumors receiving SRS who were followed at our institution with prospective data collection between 2012 and 2022. We analyzed clinical, molecular, and imaging data to assess relationship to outcomes and tumor control. RESULTS The median overall survival from initial SRS and from breast cancer diagnosis was 25 months (95% CI 19-31 months) and 130 months (95% CI 100-160 months), respectively. Sixteen patients (17%) achieved long-term survival (survival ≥5 years from SRS), 9 of whom are still alive. Predictors of long-term survival included HER2+ status ( P = .041) and treatment with TT ( P = .046). A limited number of patients (11%) died of central nervous system (CNS) causes. A predictor of CNS-related death was the development of leptomeningeal disease after SRS ( P = .025), whereas predictors of non-CNS death included extracranial metastases at first SRS ( P = .017), triple-negative breast cancer ( P = .002), a Karnofsky Performance Status of <80 at first SRS ( P = .002), and active systemic disease at last follow-up ( P = .001). Only 13% of patients eventually needed whole brain radiotherapy. Among the long-term survivors, none died of CNS progression. CONCLUSION Patients with BCBM can achieve long-term survival. The use of TT and HER2+ disease are associated with long-term survival. The primary cause of death was extracranial disease progression, and none of the patients living ≥5 years died of CNS-related disease.
Collapse
Affiliation(s)
- Elad Mashiach
- Department of Neurological Surgery, NYU Langone Health, New York University, New York , New York , USA
| | - Juan Diego Alzate
- Department of Neurological Surgery, NYU Langone Health, New York University, New York , New York , USA
| | | | - Kenneth Bernstein
- Department of Radiation Oncology, NYU Langone Health, New York University, New York , New York , USA
| | - Bernadine R Donahue
- Department of Radiation Oncology, NYU Langone Health, New York University, New York , New York , USA
| | - Zane Schnurman
- Department of Neurological Surgery, NYU Langone Health, New York University, New York , New York , USA
| | - Jason Gurewitz
- Department of Radiation Oncology, NYU Langone Health, New York University, New York , New York , USA
| | - Lauren E Rotman
- Department of Neurological Surgery, NYU Langone Health, New York University, New York , New York , USA
| | - Sylvia Adams
- Department of Medical Oncology, Perlmutter Cancer Center, NYU Langone Health, New York University, New York , New York , USA
- Department of Medicine, NYU Langone Health, New York University, New York , New York , USA
| | - Marleen Meyers
- Department of Medical Oncology, Perlmutter Cancer Center, NYU Langone Health, New York University, New York , New York , USA
- Department of Medicine, NYU Langone Health, New York University, New York , New York , USA
| | - Ruth Oratz
- Department of Medical Oncology, Perlmutter Cancer Center, NYU Langone Health, New York University, New York , New York , USA
- Department of Medicine, NYU Langone Health, New York University, New York , New York , USA
| | - Yelena Novik
- Department of Medical Oncology, Perlmutter Cancer Center, NYU Langone Health, New York University, New York , New York , USA
- Department of Medicine, NYU Langone Health, New York University, New York , New York , USA
| | - Maryann J Kwa
- Department of Medical Oncology, Perlmutter Cancer Center, NYU Langone Health, New York University, New York , New York , USA
- Department of Medicine, NYU Langone Health, New York University, New York , New York , USA
| | - Joshua S Silverman
- Department of Radiation Oncology, NYU Langone Health, New York University, New York , New York , USA
| | - Erik P Sulman
- Department of Radiation Oncology, NYU Langone Health, New York University, New York , New York , USA
| | - John G Golfinos
- Department of Neurological Surgery, NYU Langone Health, New York University, New York , New York , USA
| | - Douglas Kondziolka
- Department of Neurological Surgery, NYU Langone Health, New York University, New York , New York , USA
| |
Collapse
|
3
|
Fiore G, Tariciotti L, Bertani GA, Gagliano D, D’Ammando A, Ampollini AM, Schisano L, Borsa S, Pluderi M, Locatelli M, Caroli M. Surgery vs. Radiosurgery for Patients with Localized Metastatic Brain Disease: A Systematic Review with Meta-Analysis of Randomized Controlled Trials. Cancers (Basel) 2023; 15:3802. [PMID: 37568618 PMCID: PMC10417431 DOI: 10.3390/cancers15153802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 07/18/2023] [Accepted: 07/25/2023] [Indexed: 08/13/2023] Open
Abstract
Purpose: To analyze the efficacy and safety of surgery compared to radiosurgery (RS), combined or not with whole brain radiotherapy (WBRT), for localized metastatic brain disease. Methods: A systematic review with meta-analysis was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. The inclusion criteria were limited to randomized controlled trials (RCTs) that compared surgery and RS for patients with up to 3 metastases (median diameter ≤ 4 cm). The primary outcomes were represented by overall survival (OS) and local brain progression-free survival (PFS), with the rate of complications as a secondary outcome. The pooled estimates were calculated using random forest models. The risk of bias was evaluated using the RoB2 revised tool and the certainty of the evidence was assessed according to the GRADE guidelines. Results: In total, 11,256 records were identified through database and register searches. After study selection, 3 RCTs and 353 patients were included in the quantitative synthesis. Surgery and RS represented the main intervention arms in all the included RCTs. Conclusions: A low level of evidence suggests that RS alone and surgery followed by WBRT provide an equal rate of local brain PFS in patients with localized metastatic brain disease. There is a very low level of evidence that surgery and RS as main interventions offer equivalent OS in the population investigated. A reliable assessment of the complication rates among surgery and RS was not achievable. The lack of high-certainty evidence either for superiority or equivalence of these treatments emphasizes the need for further, more accurate, RCTs comparing surgery and RS as local treatment in patients with oligometastatic brain disease.
Collapse
Affiliation(s)
- Giorgio Fiore
- Unit of Neurosurgery, IRCCS Ca’ Granda Foundation Ospedale Maggiore Policlinico, Via Francesco Sforza, 35, 20122 Milan, Italy
- Department of Medical and Surgical Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK
| | - Leonardo Tariciotti
- Unit of Neurosurgery, IRCCS Ca’ Granda Foundation Ospedale Maggiore Policlinico, Via Francesco Sforza, 35, 20122 Milan, Italy
- Department of Medical and Surgical Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy
| | - Giulio Andrea Bertani
- Unit of Neurosurgery, IRCCS Ca’ Granda Foundation Ospedale Maggiore Policlinico, Via Francesco Sforza, 35, 20122 Milan, Italy
| | - Dario Gagliano
- Unit of Neurosurgery, IRCCS Ca’ Granda Foundation Ospedale Maggiore Policlinico, Via Francesco Sforza, 35, 20122 Milan, Italy
- Department of Medical and Surgical Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy
| | - Antonio D’Ammando
- Unit of Neurosurgery, IRCCS Ca’ Granda Foundation Ospedale Maggiore Policlinico, Via Francesco Sforza, 35, 20122 Milan, Italy
| | - Antonella Maria Ampollini
- Unit of Neurosurgery, IRCCS Ca’ Granda Foundation Ospedale Maggiore Policlinico, Via Francesco Sforza, 35, 20122 Milan, Italy
| | - Luigi Schisano
- Unit of Neurosurgery, IRCCS Ca’ Granda Foundation Ospedale Maggiore Policlinico, Via Francesco Sforza, 35, 20122 Milan, Italy
| | - Stefano Borsa
- Unit of Neurosurgery, IRCCS Ca’ Granda Foundation Ospedale Maggiore Policlinico, Via Francesco Sforza, 35, 20122 Milan, Italy
| | - Mauro Pluderi
- Unit of Neurosurgery, IRCCS Ca’ Granda Foundation Ospedale Maggiore Policlinico, Via Francesco Sforza, 35, 20122 Milan, Italy
| | - Marco Locatelli
- Unit of Neurosurgery, IRCCS Ca’ Granda Foundation Ospedale Maggiore Policlinico, Via Francesco Sforza, 35, 20122 Milan, Italy
- Department of Medical and Surgical Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy
| | - Manuela Caroli
- Unit of Neurosurgery, IRCCS Ca’ Granda Foundation Ospedale Maggiore Policlinico, Via Francesco Sforza, 35, 20122 Milan, Italy
| |
Collapse
|
4
|
Berger A, Mullen R, Bernstein K, Alzate JD, Silverman JS, Sulman EP, Donahue BR, Chachoua A, Shum E, Velcheti V, Sabari J, Golfinos JG, Kondziolka D. Extended Survival in Patients With Non-Small-Cell Lung Cancer-Associated Brain Metastases in the Modern Era. Neurosurgery 2023; 93:50-59. [PMID: 36722962 DOI: 10.1227/neu.0000000000002372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 11/17/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Brain metastases (BM) have long been considered a terminal diagnosis with management mainly aimed at palliation and little hope for extended survival. Use of brain stereotactic radiosurgery (SRS) and/or resection, in addition to novel systemic therapies, has enabled improvements in overall and progression-free (PFS) survival. OBJECTIVE To explore the possibility of extended survival in patients with non-small-cell lung cancer (NSCLC) BM in the current era. METHODS During the years 2008 to 2020, 606 patients with NSCLC underwent their first Gamma Knife SRS for BM at our institution with point-of-care data collection. We reviewed clinical, molecular, imaging, and treatment parameters to explore the relationship of such factors with survival. RESULTS The median overall survival was 17 months (95% CI, 13-40). Predictors of increased survival in a multivariable analysis included age <65 years ( P < .001), KPS ≥80 ( P < .001), absence of extracranial metastases ( P < .001), fewer BM at first SRS (≤3, P = .003), and targeted therapy ( P = .005), whereas chemotherapy alone was associated with shorter survival ( P = .04). In a subgroup of patients managed before 2016 (n = 264), 38 (14%) were long-term survivors (≥5 years), of which 16% required no active cancer treatment (systemic or brain) for ≥3 years by the end of their follow-up. CONCLUSION Long-term survival in patients with brain metastases from NSCLC is feasible in the current era of SRS when combined with the use of effective targeted therapeutics. Of those living ≥5 years, the chance for living with stable disease without the need for active treatment for ≥3 years was 16%.
Collapse
Affiliation(s)
- Assaf Berger
- Department of Neurological Surgery, NYU Langone Health Medical Center, New York University, New York, New York, USA
| | - Reed Mullen
- Department of Neurological Surgery, NYU Langone Health Medical Center, New York University, New York, New York, USA
| | - Kenneth Bernstein
- Department of Radiation Oncology, NYU Langone Health Medical Center, New York University, New York, New York, USA
| | - Juan Diego Alzate
- Department of Neurological Surgery, NYU Langone Health Medical Center, New York University, New York, New York, USA
| | - Joshua S Silverman
- Department of Radiation Oncology, NYU Langone Health Medical Center, New York University, New York, New York, USA
| | - Erik P Sulman
- Department of Radiation Oncology, NYU Langone Health Medical Center, New York University, New York, New York, USA
| | - Bernadine R Donahue
- Department of Radiation Oncology, NYU Langone Health Medical Center, New York University, New York, New York, USA
| | - Abraham Chachoua
- Medical Oncology, Perlmutter Cancer Center, NYU Langone Health Medical Center, New York University, New York, New York, USA
| | - Elaine Shum
- Medical Oncology, Perlmutter Cancer Center, NYU Langone Health Medical Center, New York University, New York, New York, USA
| | - Vamsidhar Velcheti
- Medical Oncology, Perlmutter Cancer Center, NYU Langone Health Medical Center, New York University, New York, New York, USA
| | - Joshua Sabari
- Medical Oncology, Perlmutter Cancer Center, NYU Langone Health Medical Center, New York University, New York, New York, USA
| | - John G Golfinos
- Department of Neurological Surgery, NYU Langone Health Medical Center, New York University, New York, New York, USA
| | - Douglas Kondziolka
- Department of Neurological Surgery, NYU Langone Health Medical Center, New York University, New York, New York, USA
| |
Collapse
|
5
|
Wang J, Hu K, Qian H, Yuan Q, Liu Q, Ma C, Shao L, Wan J. Systemic immune‐inflammation landscape in brain metastasis needing neurosurgical resection: Analysis of 230 consecutive cases in a single center. Immun Inflamm Dis 2022; 10:e694. [PMID: 36169253 PMCID: PMC9449592 DOI: 10.1002/iid3.694] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 07/16/2022] [Accepted: 08/20/2022] [Indexed: 12/12/2022] Open
Abstract
Background Systemic immune‐inflammation states across the heterogeneous population of brain metastases are very important in the context of brain‐immune bidirectional communication, especially among the patients needing neurosurgical resection. Four blood cell ratios based on complete blood count (CBC) test serving as prognostic biomarkers have been highlighted by previous studies, including systemic immune‐inflammation index (SII), neutrophil‐to‐lymphocyte ratio (NLR), platelet‐to‐lymphocyte ratio (PLR), and lymphocyte‐to‐monocyte ratio (LMR). However, the presurgical systemic immune‐inflammation landscape in brain metastasis needing neurosurgical resection is limited. Methods Patients with brain metastases admitted to the Department of Neurosurgery at the National Cancer Center, Cancer Hospital of Chinese Academy of Medical Sciences between January 2016 and December 2019 were included. Based on peripheral blood cell counts in CBC test before neurosurgical resection, four systemic immune‐inflammation biomarkers (SII, NLR, PLR, and LMR) were calculated. We characterized the changes of SII, NLR, PLR, and LMR in patients with brain metastasis before neurosurgical resection and the associations of these types of immune‐inflammation states with patient demographics. In parallel, the corresponding data from the relative healthy populations without systemic diseases were enrolled as the control in the present study. Results Brain metastases induced systemic immune‐inflammation perturbation, which was characterized by a significant increase in SII (p < .01) and NLR levels (p < .01) and a significant decrease in the LMR level (p < .01) in comparison with the healthy control group. Moreover, patients with male gender, less Karnofsky Performance Status (KPS) scores (<70), specific pathological subtypes, extracranial transfer, and history of both systemic and radiation therapy may have significant differences in one or more of these biomarkers, which indicated poorer systemic immune‐inflammation states. Conclusions This study provides evidence that brain metastasis is associated with perturbations in presurgical systemic immune‐inflammation states. We should pay attention to the systemic immune‐inflammation perturbations following brain metastasis in clinic, especially in the subpopulations with high risks.
Collapse
Affiliation(s)
- Jia‐Wei Wang
- Department of Neurosurgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital Chinese Academy of Medical Sciences and Peking Union Medical College Beijing People's Republic of China
| | - Ke Hu
- Department of Neurosurgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital Chinese Academy of Medical Sciences and Peking Union Medical College Beijing People's Republic of China
| | - Hai‐Peng Qian
- Department of Neurosurgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital Chinese Academy of Medical Sciences and Peking Union Medical College Beijing People's Republic of China
| | - Qing Yuan
- Department of Neurosurgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital Chinese Academy of Medical Sciences and Peking Union Medical College Beijing People's Republic of China
| | - Qi Liu
- Department of Neurosurgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital Chinese Academy of Medical Sciences and Peking Union Medical College Beijing People's Republic of China
| | - Chao Ma
- Department of Neurosurgery, The Third People's Hospital of Hefei Hefei Third Clinical College of Anhui Medical University Hefei People's Republic of China
| | - Liujiazi Shao
- Department of Anesthesiology, Beijing Friendship Hospital Capital Medical University Beijing People's Republic of China
| | - Jing‐Hai Wan
- Department of Neurosurgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital Chinese Academy of Medical Sciences and Peking Union Medical College Beijing People's Republic of China
| |
Collapse
|
6
|
Long-Term Survival after Linac-Based Stereotactic Radiosurgery and Radiotherapy with a Micro-Multileaf Collimator for Brain Metastasis. Curr Oncol 2022; 29:6068-6076. [PMID: 36135046 PMCID: PMC9497847 DOI: 10.3390/curroncol29090477] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 08/22/2022] [Accepted: 08/22/2022] [Indexed: 11/24/2022] Open
Abstract
Background: this study aimed to evaluate the prognostic factors associated with long-term survival after linear accelerator (linac)-based stereotactic radiosurgery (SRS) and fractionated stereotactic radiotherapy (fSRT) with a micro-multileaf collimator for brain metastasis (BM). Methods: This single-center retrospective study included 226 consecutive patients with BM who were treated with linac-based SRS or fSRT with a micro-multileaf collimator between January 2011 and December 2018. Long-term survival (LTS) was defined as survival for more than 2 years after SRS/fSRT. Results: The tumors originated from the lung (n = 189, 83.6%), breast (n = 11, 4.9%), colon (n = 9, 4.0%), stomach (n = 4, 1.8%), kidney (n = 3, 1.3%), esophagus (n = 3, 1.3%), and other regions (n = 7, 3.1%). The median pretreatment Karnofsky performance scale (KPS) score was 90 (range: 40–100). The median follow-up time was 13 (range: 0–120) months. Out of the 226 patients, 72 (31.8%) were categorized in the LTS group. The median survival time was 43 months and 13 months in the LTS group and in the entire cohort, respectively. The 3-year, 4-year, and 5-year survival rate in the LTS group was 59.1%, 49.6%, and 40.7%, respectively. Multivariate regression logistic analysis showed that female sex, a pre-treatment KPS score ≥ 80, and the absence of extracranial metastasis were associated with long-term survival. Conclusions: female sex, a favorable pre-treatment KPS score, and the absence of extracranial metastasis were associated with long-term survival in the current cohort of patients with BM.
Collapse
|
7
|
Wang Y, Delisle M, Smith D, Alshamsan B, Srikanthan A. Clinical outcomes of brain metastasectomy from soft tissue and bone sarcomas: a systematic review. Int J Clin Oncol 2022; 27:1767-1779. [PMID: 35994183 DOI: 10.1007/s10147-022-02227-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 07/31/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Brain metastasis in sarcomas is associated with a poor prognosis. Data regarding prognostic factors and clinical outcomes of surgical resection of brain metastasis from sarcomas are limited. The objective of this systematic review was to evaluate survival outcomes post-brain metastasectomy for patients with soft tissue and bone sarcomas. METHODS A systematic review was conducted examining survival outcomes among adults and children with soft tissue and bone sarcoma undergoing brain metastasectomy, in the English language from inception up to May 31, 2021. Two reviewers independently evaluated and screened the literature, extracted the data, and graded the included studies. The body of evidence was evaluated and graded according to the Newcastle-Ottawa Quality Assessment Scale for Cohort Studies and the Joanna Briggs Institute Critical Appraisal Checklist for Case Series. Results were synthesized using descriptive methods. A meta-analysis was not possible due to the low quality and heterogeneity of studies. RESULTS Ten studies published between 1994 and 2020 were included: three were retrospective cohort studies and seven were case series. 507 patients were included, of whom 269 underwent brain metastasectomy. The median follow-up period ranged between 14 and 29 months. The median survival period after metastasectomy ranged from 7 to 25 months. The most common prognostic factors associated with survival included presenting performance status, age, number of brain metastases, presence of lung metastases, and peri-operative radiation therapy administration. DISCUSSION Although the level of evidence is low, retrospective studies support that brain metastasectomy can be performed with reasonable post-operative survival in selected individuals.
Collapse
Affiliation(s)
- Ying Wang
- Division of Medical Oncology, Department of Medicine, University of British Columbia, Vancouver, BC, V5Z 4E6, Canada
| | - Megan Delisle
- Division of Surgery, The Ottawa Hospital, Ottawa, ON, K1H8L6, Canada
| | - Denise Smith
- McMaster University, Health Sciences Library, 1280 Main Street West, Hamilton, ON, L8S 4L8, Canada
| | - Bader Alshamsan
- Division of Medical Oncology, Department of Medicine, University of Ottawa, Ottawa, ON, K1H 8L6, Canada.,Department of Medicine, College of Medicine, Qassim University, Buraydah, Saudi Arabia
| | - Amirrtha Srikanthan
- Division of Medical Oncology, Department of Medicine, University of Ottawa, Ottawa, ON, K1H 8L6, Canada. .,Department of Medicine, Division of Medical Oncology, The Ottawa Hospital Cancer Centre, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada. .,Ottawa Hospital Research Institute, Ottawa, ON, K1Y4E9, Canada.
| |
Collapse
|
8
|
Kuntz L, Le Fèvre C, Jarnet D, Keller A, Meyer P, Cox DG, Bund C, Antoni D, Cebula H, Noel G. Radionecrosis after repeated courses of radiotherapy under stereotactic conditions for brain metastases: Analysis of clinical and dosimetric data from a retrospective cohort of 184 patients. Cancer Radiother 2022; 26:692-702. [PMID: 35715354 DOI: 10.1016/j.canrad.2022.01.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 12/27/2021] [Accepted: 01/05/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Between 10 and 40% of patients with cancer will develop one or more brain metastases (BMs). Stereotactic radiotherapy (SRT) is part of the therapeutic arsenal for the treatment of de novo or recurrent BM. Its main interest is to delay whole brain radiation therapy (WBRT), which may cause cognitive toxicity. However, SRT is not exempt from long-term toxicity, and the most widely known SRT is radionecrosis (RN). The objective of this study was to analyze the occurrence of RN per BM and per patient. MATERIAL AND METHODS Between 2010 and 2020, data from 184 patients treated for 915 BMs by two to six SRT sessions for local or distant brain recurrence without previous or intercurrent WBRT were retrospectively reviewed. RN was examined on trimestral follow-up MRI and potentially confirmed by surgery or nuclear medicine. For each BM and SRT session plan, summation V12Gy, V14Gy, V21Gy and V23Gy isodoses were collected. Volumes of intersections were created between the 12Gy isodose at the first SRT and the 18Gy isodose of the following SRT (V18-12Gy). RESULTS At the end of follow-up, 23.0% of patients presented RN, and 6.3% of BM presented RN. Median follow-up of BM was 13.3 months (95%CI 18.3-20.8). The median interval between BM irradiation and RN was 8.7 months (95% CI 9.2-14.7). Six-, 12- and 24-month RN-free survival rates per BM were 75%, 54% and 29%, respectively. The median RN-free survival per patient was 15.3 months (95% CI 13.6-18.1). In multivariate analysis, the occurrence of RN per BM was statistically associated with local reirradiation (P<0.001) and the number of SRTs (P<0.001). In univariate analysis, the occurrence of RN per patient was statistically associated with the sum of all V18-12Gy (P=0.02). No statistical association was found in multivariate analysis. A sum of all V18-12Gy of less than 1.5ml was associated with a 14.6% risk of RN, compared with 35.6% when the sum of all V18-12Gy was superior to 1.5ml. The sum of all V18-12Gy larger than 1.5ml was associated with a 74% specificity and 53% sensitivity of RN (P<0.001). CONCLUSION Based on these results, a small number of BMs show RN during repeated SRT for local or distant recurrent BMs. Local reirradiation was the most predictive factor of brain RN. A V18-12Gy larger than 7.6ml in the case of local reirradiation or larger than 1.5ml in proximity reirradiation were prognostic factors of RN. The more BM patients need radiation therapy, and the longer they survive after irradiation, the higher their individual risk of developing RN.
Collapse
Affiliation(s)
- L Kuntz
- Radiation Therapy University Department, Institut de Cancérologie Strasbourg Europe (ICANS), 17, rue Albert-Calmette, 67200 Strasbourg, France
| | - C Le Fèvre
- Radiation Therapy University Department, Institut de Cancérologie Strasbourg Europe (ICANS), 17, rue Albert-Calmette, 67200 Strasbourg, France
| | - D Jarnet
- Medical Physics Unit, Institut de Cancérologie Strasbourg Europe (ICANS), 17, rue Albert-Calmette, 67200 Strasbourg, France
| | - A Keller
- Radiation Therapy University Department, Institut de Cancérologie Strasbourg Europe (ICANS), 17, rue Albert-Calmette, 67200 Strasbourg, France
| | - P Meyer
- Medical Physics Unit, Institut de Cancérologie Strasbourg Europe (ICANS), 17, rue Albert-Calmette, 67200 Strasbourg, France
| | - D G Cox
- IRFAC, Inserm U1113, 3, avenue Molière, 67000 Strasbourg, France; Research and Development in Precision Medicine, Institut de Cancérologie Strasbourg Europe (ICANS), 17, rue Albert-Calmette, 67200 Strasbourg, France
| | - C Bund
- Biophysics and Nuclear Medicine, University Hospitals of Strasbourg, 1, avenue Molière, 67200 Strasbourg, France
| | - D Antoni
- Radiation Therapy University Department, Institut de Cancérologie Strasbourg Europe (ICANS), 17, rue Albert-Calmette, 67200 Strasbourg, France
| | - H Cebula
- Department of Neurosurgery, University Hospitals of Strasbourg, 1, avenue Molière, 67200 Strasbourg, France
| | - G Noel
- Radiation Therapy University Department, Institut de Cancérologie Strasbourg Europe (ICANS), 17, rue Albert-Calmette, 67200 Strasbourg, France.
| |
Collapse
|
9
|
Significant survival improvements for patients with melanoma brain metastases: can we reach cure in the current era? J Neurooncol 2022; 158:471-480. [PMID: 35665462 DOI: 10.1007/s11060-022-04036-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 05/12/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE New therapies for melanoma have been associated with increasing survival expectations, as opposed to the dismal outcomes of only a decade ago. Using a prospective registry, we aimed to define current survival goals for melanoma patients with brain metastases (BM), based on state-of-the-art multimodality care. METHODS We reviewed 171 melanoma patients with BM receiving stereotactic radiosurgery (SRS) who were followed with point-of-care data collection between 2012 and 2020. Clinical, molecular and imaging data were collected, including systemic treatment and radiosurgical parameters. RESULTS Mean age was 63 ± 15 years, 39% were female and 29% had BRAF-mutated tumors. Median overall survival after radiosurgery was 15.7 months (95% Confidence Interval 11.4-27.7) and 25 months in patients managed since 2015. Thirty-two patients survived [Formula: see text] 5 years from their initial SRS. BRAF mutation-targeted therapies showed a survival advantage in comparison to chemotherapy (p = 0.009), but not to immunotherapy (p = 0.09). In a multivariable analysis, both immunotherapy and the number of metastases at 1st SRS were predictors of long-term survival ([Formula: see text] 5 years) from initial SRS (p = 0.023 and p = 0.018, respectively). Five patients (16%) of the long-term survivors required no active treatment for [Formula: see text] 5 years. CONCLUSION Long-term survival in patients with melanoma BM is achievable in the current era of SRS combined with immunotherapies. For those alive [Formula: see text] 5 years after first SRS, 16% had been also off systemic or local brain therapy for over 5 years. Given late recurrences of melanoma, caution is warranted, however prolonged survival off active treatment in a subset of our patients raises the potential for cure.
Collapse
|
10
|
Abstract
Imaging of brain metastases (BMs) has advanced greatly over the past decade. In this review, we discuss the main challenges that BMs pose in clinical practice and describe the role of imaging.Firstly, we describe the increased incidence of BMs of different primary tumours and the rationale for screening. A challenge lies in selecting the right patients for screening: not all cancer patients develop BMs in their disease course.Secondly, we discuss the imaging techniques to detect BMs. A three-dimensional (3D) T1W MRI sequence is the golden standard for BM detection, but additional anatomical (susceptibility weighted imaging, diffusion weighted imaging), functional (perfusion MRI) and metabolic (MR spectroscopy, positron emission tomography) information can help to differentiate BMs from other intracranial aetiologies.Thirdly, we describe the role of imaging before, during and after treatment of BMs. For surgical resection, imaging is used to select surgical patients, but also to assist intraoperatively (neuronavigation, fluorescence-guided surgery, ultrasound). For treatment planning of stereotactic radiosurgery, MRI is combined with CT. For surveillance after both local and systemic therapies, conventional MRI is used. However, advanced imaging is increasingly performed to distinguish true tumour progression from pseudoprogression.FInally, future perspectives are discussed, including radiomics, new biomarkers, new endogenous contrast agents and theranostics.
Collapse
Affiliation(s)
- Sophie H A E Derks
- Department of Neuro-Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands.,Department of Radiology & Nuclear Medicine, Erasmus Medical Center, Rotterdam, The Netherlands.,Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Astrid A M van der Veldt
- Department of Radiology & Nuclear Medicine, Erasmus Medical Center, Rotterdam, The Netherlands.,Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Marion Smits
- Department of Radiology & Nuclear Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| |
Collapse
|